Suhani Jalota was only 20 years old when she established a foundation to help impoverished women in the slums of her native city, Mumbai. She was 23 when Forbes named her one of Asia’s 30-Under-30 Social Entrepreneurs as her foundation was taking off.

Now, at the ripe old age of 24, she is embarking on her pursuit of a PhD in health policy on the econ track at Stanford Medicine’s Department of Health Research and Policy.

As a social entrepreneur, she is hoping to create self-sustaining health organizations managed entirely by the people in the low-income communities they serve.

Last year, Jalota, who is also in the first cohort of Knight-Hennessy Scholars, received the Queen’s Young Leader award from Queen Elizabeth II and attended the royal wedding of Prince Harry and American actress Meghan Markle, who is now Duchess of Sussex.

The Myna Mahila Foundation— which provides affordable sanitary products and promotes employment and empowerment among women in Mumbai’s slums — was the only non-UK charity chosen to receive donations in lieu of gifts for the royal couple.

Stanford Health Policy caught up with Jalota to ask her a few questions about what inspires her and how she became so passionate about sanitary health and empowering women in India.

Who inspired you to become social-entrepreneur at such a young age?

I come from a government family and, growing up, our conversations at home were always about the development of India and the status of women. My father is an Indian civil servant who has worked on water sanitation for the city; my mom works with underprivileged girl children, and my brother creates water filters for the same slum community. My grandparents were in the police. It’s just what we do. It’s our family calling. 

As for entrepreneurship, it was Duke University, the Baldwin Scholars Program and the Melissa and Doug Entrepreneurship Fellowship that actually made me believe that all the dreams I had to change the pitiful state of things on the ground in Mumbai could actually be achievable. There I learned to translate the problems I saw to actionable items that the institution was willing to back and support endlessly.

Then in 2011, I met Dr. Jockin Arputham, who spent 40 years working in the slums of Mumbai as the founder of Slum Dwellers International. He became my inspiration, my idol and my mentor. He singlehandedly improved the lives of millions of women.

Dr. Arputham passed away in October. I am here to complete this mission.

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What inspired you to establish the Myna Mahila Foundation? 

When I started spending more time with women in the slum communities they told me horrific stories about living on the railway tracks, children dying in front of them, and not being able to walk the public toilets without being sexually harassed. Some were taking pills to constipate themselves just so they did not have to go to the public toilet. Others would tell me how they had been married off at 12 and were still living with drunk husbands who beat them every day. 

Women were ignoring their own health and it really struck me as how this would lead to such wasted potential for the women, and for India.

The slum community leaders and I began brainstorming — we became very chatty. That’s where the name comes from. Myna from the chatty South Asian bird and Mahila, which means women in Hindi. And we found that their menstrual cycles were physically and mentally exhausting. We found that sanitation and hygiene were clear signals of dignity for women, so we jumped on that.

You see, 320 million women in India do not have access to sanitary pads. And menstruation in India is a taboo health topic; there is a stigma to shopping for sanitary pads. Most women use rags on their periods and these often become dirty, leading to urinary and vaginal infections.

When you are trapped under an aluminum roof where your horizon is the lining of the slum settlement, and you only see limitations ahead of you, it is difficult to see another way of life. After more than six years of working on sanitation and health research with these women, I realized the problems lay deeply entrenched in a woman’s lack of agency, or ability to make decisions. You are brought up to think that what the generations ahead of you have been doing is the only way of life. Hiding your periods, not cooking food or sleeping with the family during your periods, not going to the temple or playing sports — you believe this is the only way to live.

So we came up with a scheme to sell sanitary pads door-to-door to women who would normally not leave their homes or go to a pharmacy to buy them from male clerks. And we get to know these women; they are opening up and exploring things outside the confines of their husbands’ world. I learned that if women were confident to talk about their periods and menstrual hygiene, it could break the silence surrounding domestic violence or sanitation.

Tell us about the women who work for you and the women you serve. 

We employ women from the slum communities we serve, including the accountants, production and sales managers, and the education trainers. We work mostly with Muslim women as that is a representation of the demographics of the communities we are in.

We currently meet about 10,000 women at their doorsteps every month in the 12 slums across Mumbai. It’s not about giving out free pads — a woman gets her period 450 times in her lifetime, so what we’re trying to do is make sure that she understands that it’s a normal health cycle that should not stop her from getting her education and jobs. We have more than 500 girls in our sponsor a girl program, with 100 more girls joining every month. We hold individual counseling and mentorship for these girls along with menstrual hygiene workshops at health camps. We employ 20 women and have partnerships with self-help groups across the city who work with us part-time.

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In the words of my mentor Dr. Arputham, it’s not our purpose to tell the women in the slums what to do; you must think about it from their perspective of what they need and help them create their own change. This has been my mission ever since.

We have millions of NGOs in India so you realize that if things are not really improving at a national level, then there’s something that we’re not doing right. We need the civic mindset to marry the efficiency of the business world. This makes people less dependent and more autonomous to be in control of their own situations. And that comes with a sense of pride.

Why focus on health and sanitation?

We are still struggling with the basics in India: basic health, which includes food, housing, potable water and improved sanitation. Numerous research studies have demonstrated that improvements in sanitation have led to dramatic improvements in health, such as life expectancy outcome measures. Unless we have basic health standards achieved, we will remain behind. To add to the problem, health-care is often deprioritized in India. While it accounts for nearly 18 percent of the GDP here in the United States, for example, it only accounts for 1 percent in India. Can you imagine that? With more than 1 billion people. The role of the public sector in India is to get people on the same level playing field with the basics: education, health care so you’re well enough to go to school or work, find food, shelter and water.

India is a true democracy — so if people start to recognize the importance of health and demand better health care, they can get it. 

What are your goals for the PhD?

To learn more research techniques to use for conducting experiments on the ground for a variety of topics, including women’s demand for health care, effects of positions of power in seeking health care, and the connection between environment and health. On the supply side, I am becoming increasingly interested in understanding pay-for-performance incentive structures in health institutions and for front-line health workers.

I will also be spending my December breaks and summers in India working at the foundation. After my second year, I hope to continue data collection for my dissertation topic: the effect of environmental changes on health outcomes, such as child stunting levels in the slums. As part of my undergrad thesis, I collected anthropometric data on 880 children to look at the effect of slum redevelopment (when the government forcibly relocates people from slums to government subsidized housing) on child stunting. I learned that when a child has one additional year in the buildings — instead of out in the slums with no toilets and clean water and proper ventilation — they were less likely to be stunted. The effect was even more pronounced (and significant) for children moving from slums without toilets than for children moving from slums with toilets.

Another area of research for me moving forward is how this plays out if a pregnant mother gives birth in the slums or the building. Is that affecting the child’s birth weight? Is water quality, sanitation, population density — have other health outcomes actually improved?

You could have gone anywhere for your PhD. Why Stanford?

The Knight Hennessy Scholars Program — that was a very compelling pull. Further, I think that being at Stanford gives you this additional advantage of having access to really positive technology like Virtual Reality — giving people exposure to a different world. We want people to demand better health care, so if they can experience what it feels like to walk into a hospital and a clean waiting room with a bench and a trash can, it can change their concept of what they deserve. I’m really excited to learn more about how new technologies can be applied in the slums to prompt people to stand up and demand better for themselves.

I took two women who work at Myna Mahila with me to the royal wedding. These are women who come from the slums — and what impressed them most was the cleanliness. They couldn’t believe how people could keep everything so clean. If more women see this through VR, they will start to think that this world should become theirs too. We have access to thousands of women and if we can teach menstrual hygiene education through this technology — well, as an entrepreneur, I get very excited about this. This is just one of the many technologies I want to learn more about and see if they can be applied in the slums.

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What did you make of Meghan Markle’s visit to the foundation in January 2017?

When she came to visit she told us she would support us in any way that she could. She kept her word. For us being chosen as one of seven charities for the royal wedding, I thought to myself, oh my God, she really thinks that we’re on to something that could actually change the world for many women. I feel like I have a huge responsibility to live up to their expectations. Now we have to keep our word to them and help women meet their true potential.

Preeclampsia is a serious complication of pregnancy that affects 5 to 10 percent of all pregnancies — over 8 million a year worldwide — and claims the lives of 76,000 mothers and half a million babies each year.

The condition causes hypertension and abnormal protein in the urine, and has few effective preventive or therapeutic strategies. The clinical abnormalities usually resolve completely after delivery, but recent research shows that women who have had preeclampsia have higher rates of heart disease later in life, for reasons that are poorly understood.

That’s where Mark Hlatky, Virginia Winn, and their Stanford Medicine research team come in. They were recently awarded a 4-year, $6 million NIH grant from the National Heart, Lung and Blood Institute to study the links between preeclampsia and the subsequent risk of atherosclerotic cardiovascular disease (ASCVD) as women grow older.

“The goal of this study is to improve cardiovascular health in women, by learning how pregnancy affects heart disease later in life,” said Hlatky, a Stanford Health Policy fellow. “We hope that shedding new light on these links can lead to better prevention and treatment.”

The interdisciplinary study called EPOCH — Effect of Preeclampsia On Cardiovascular Health — could eventually help millions of women and their clinicians worldwide.

“Since about 85 percent of women become pregnant at some point during their lives, and heart disease is the leading cause of death in women, determining how pregnancy complications might increase the risk of heart disease later in life could be very important,” said Hlatky, a professor of health research and policy and of cardiovascular medicine. “If there is a specific biomarker ‘signature’ of heart disease risk in women who have had preeclampsia, it would open up new possibilities for risk assessment and better treatment to prevent heart attacks and strokes.”

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Hlatky and his co-principal investigator, Stanford high-risk obstetrician Winn, note that a history of preeclampsia doubles the woman’s risk of future heart disease and stroke, and triples her risk of hypertension. And these adverse consequences occur at younger ages than in women who never developed the condition during pregnancy.

"The dramatic physiologic changes that happen during pregnancy are indeed remarkable," said Winn, the Arline and Pete Harman faculty scholar in the Department of Obstetrics and Gynecology. "This study highlights how complications that occur in pregnancy impact women's health beyond pregnancy." 

The pathogenic links between preeclampsia early in life and ASCVD late in life have been difficult to investigate because the process develops over decades, the authors said. And few clinicians are aware of the link between the condition and late ASCVD risk and there are no validated biomarkers for this process.

Preliminary data that contributed to the application of the project was a direct result of Winn’s endowed Arline and Pete Harman Faculty Scholar award and funding from the Stanford Maternal and Child Health Research Institute and the Stanford Cardiovascular Institute.

The 4-year grant will support a multi-disciplinary research team in taking a life-course approach. The EPOCH study will enroll three cohorts of women at distinct points in the natural history of the disorder: during pregnancy in their reproductive years; during the long, asymptomatic period in mid-life; and the ultimate development of ASCVD in later life.

“It’s very difficult to study the effects of early life events on the development of diseases late in life, since they are separated by 40 years or more,” Hlatky said. “We don’t have reliable health records in the United States from 40 or more years ago, so it’s a challenge for American researchers.” This is why, he said, the EPOCH study includes researchers from Denmark, which has a national health system, complete medical data of their citizens since the 1970’s, and a national biobank that will allow study of later life events.

The first cohort of women will include some of those who are already part of the Stanford March of Dimes Prematurity Research Center. The center, led by David Stevenson began recruiting women in 2011 to study pregnancy from the first trimester through delivery. The study has collected a wide array of “omics” measures at multiple time points: metabolomics, proteomics, cell-free RNA, the microbiome and immune cells for analysis, as well as collection of amniotic fluid, cord blood, and the placenta. The pregnancy cohort will enroll additional women who are cared for at Lucile Packard Children’s Hospital for treatment of preeclampsia, about 100 in all, plus a matched group with uncomplicated pregnancies.

This is where it gets pretty technical — but also pretty cool

The researchers will collect high-dimensional “omic” biomarker data to assess the pathophysiology of preeclampsia and its relationship to cardiovascular function and disease. They’ll assess cell signaling pathways using single-cell immune profiling (CyTOF) methods in the lab of Brice Gaudilliere, an assistant professor of anesthesia.

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They will then analyze the cell-free RNA profiles using methods developed by co-investigator Stephen Quake, a professor of bioengineering and applied physics, and co-president of the Chan Zuckerberg Biohub. They will assess metabolomics using novel methods also developed at Stanford by co-investigator Michael Snyder,  professor and chair of genetics.

Stanford data scientists, including co-investigators, Robert Tibshirani and Nima Aghaeepour, have been at the forefront of developing and applying novel statistical and bioinformatic approaches, which the team will use to analyze the torrents of data that can now be collected by modern “omics” technologies from individual clinical research subjects.

“The EPOCH study is truly interdisciplinary — we are bringing together faculty from eight different departments to study a major problem in women’s health.”

The second, mid-life cohort will be recruited from women who had a pregnancy complicated by preeclampsia. Marcia Stefanick, professor of medicine in the Stanford Prevention Research Center, will use the Stanford Medicine Research Data Repository (STARR), which contains electronic records from more than 1.6 million patients since 1995, to identify eligible women. Stefanick and the EPOCH team will recruit 200 pre-menopausal women who had either a pregnancy complicated by preeclampsia or an uncomplicated pregnancy.

The third, late-life cohort of women will be identified in the Danish National Biobank by Stanford visiting professor Mads Melbye. Samples will be retrieved from women who had preeclampsia early in life and ASCD later in life, as well as a set of matched control subjects, and analyzed in Stanford laboratories.

“We’re not quite sure whether the physiologic challenges of pregnancy that result in preeclampsia simply reveal underlying cardiovascular risk, or causes change that leads to the increased risk in later life,” Winn said. “The EPOCH study will identify unique aspects of preeclampsia that links it to later ASCVD, opening potential novel approaches to improve women’s health.”

The EPOCH study brings together investigators from eight departments. Additional faculty include Gary Shaw and Seda Tierney (Pediatrics), Martin Angst (Anesthesia), Nicholas Leeper (Surgery) and Heather Boyd (Danish Biobank).

A cutting-edge treatment for blood cancer in children with promising short-term remission rates has nevertheless come under intense scrutiny due to its unprecedented cost.

Acute lymphoblastic leukemia (ALL) is the most commonly diagnosed pediatric cancer. Though treatment advances have driven five-year survival rates above 90 percent, relapse is common and ALL remains a leading cause of death from childhood cancer. Those surviving relapse typically require hematopoietic stem cell transplant (HSCT) to remain in remission.

The Food and Drug Administration last year approved tisagenlecleucel as the first anti-CD19 CAR T-cell therapy for relapsed or refractory pediatric ALL. While tisagenlecleucel-induced remission rates are encouraging compared with those of established therapies — more than 80 percent compared with less than 50 percent — a one-time infusion costs $475,000.

That makes it one of  the most expensive oncologic therapies out there, even though no studies exist to show how the therapy maintains remission in the long term.

So Stanford Health Policy’s John K. Lin, Jeremy Goldhaber-Fiebert and Douglas K. Owens, in collaboration with Kara Davis, an assistant professor of pediatrics at Stanford’s Lucile Packard Children’s Hospital, set out to determine whether the treatment is cost-effective. 

Their study was recently published in the Journal of Clinical Oncology.

“CAR-T cells are an exciting new therapy to help us cure more patients with ALL,” said Davis. “They use a patient’s own immune system to precisely target their leukemia and remission rates are impressive for patients with relapsed disease.”

The researchers note, however, it remains unknown whether tisagenlecleucel is sufficient to cure relapsed or refractory disease without a transplant.

Not only is it a very expensive treatment, it also has expensive and serious side effects, such as cytokine release syndrome, which can cause symptoms ranging from fevers and muscle aches to lethal drops in blood pressure and difficulty breathing, requiring ICU-level care.

“Given [its] high cost and broad applicability in other malignancies, a pressing question for policymakers, payers, and clinicians is whether the therapy’s cost represents reasonable value,” the authors wrote.

In order to evaluate the economic value of tisagenlecleucel, the authors created a computer simulation that modeled children with relapsed or refractory ALL. Since the durability of the therapy’s effects are unknown, they evaluated the therapy at different levels of long-term effectiveness.

Through their analyses, the authors found that at the simulation’s most optimistic projections, patients receiving tisagenlecleucel would, on average, live over a decade longer than those receiving alternative therapies. At these projections, the therapy would be cost-effective. However, at more modest long-term outcomes, its clinical and economic benefits declined.

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“The durability of CAR-T cell therapy is the main question. For many children with relapsed or refractory ALL, their disease is fatal — if the therapy results in sustained remissions, it would represent an important advance,” said lead author Lin, who is a VA Health Services Research and Development Fellow at Stanford Health Policy.

In the end, the researchers concluded that at tisagenlecleucel’s current price, its economic value is “uncertain,” as the true cost-effectiveness depends on its long-term performance, which has yet to be determined. They noted that substantial price reductions would improve its cost-effectiveness even if its long-term performance is relatively modest.

“A commonly asked question for many expensive, novel therapies is why can’t prices be lowered at least until we know how well they work,” said Goldhaber-Fiebert. 

The “Catch-22” here is that long-term effectiveness data are needed to justify a drug’s price, but current uncertainty about its effectiveness, along with its high price, means developing the data to justify its price occurs much more slowly.

“CAR-T is an individually tailored treatment that has thus far been produced for a relatively small number of patients,” Goldhaber-Fiebert said. “Its current production costs may well be very high, and certainly the companies that have spent heavily on its research and development are interested in achieving returns on their investments.”

When the effectiveness of a therapy is uncertain, some pharmaceutical companies and health policy experts have proposed something called outcomes-based payment, which is essentially a “money-back guarantee” if the therapy doesn’t work as intended.

Novartis, which developed tisagenlecleucel, has a money-back guarantee; if the patient does not achieve initial remission within the first month, they are not responsible for the payment of the therapy.

“However, we find that because most children have an initial remission, this does not materially improve cost-effectiveness,” Lin said.

He suggested that if the money-back guarantee were extended to see whether the patient relapses within a year, such a guarantee would improve the treatment’s cost-effectiveness.

The other co-authors of the study are James I. Barnes, Alex Q.L. Robinson, Benjamin J. Lerman, Brian C. Boursiquot and Yuan Jin Tan.

There are a billion guns in the world today. Those firearms took the lives of about 251,000 people in 195 countries in 2016, according to new research. 

That’s a lot of guns and fatalities, mostly by homicide, suicide and accidents with firearms.

About 35 percent of those gun deaths were by Americans committing suicide.

In the most comprehensive investigation of its kind, the findings, published this week in the Journal of the American Medical Association (JAMA), show 64 percent of firearm-related deaths were homicides, 27 percent were suicides and 9 percent were unintentional deaths.

And in all but one year of the 27-year study period — 1994 due to the Rwandan genocide — firearm deaths were more common along sidewalks than on the battlefields.

“This constitutes a major public health problem for humanity,” said Stanford Health Policy’s David Studdert, a professor of medicine and professor of law.

In an accompanying editorial alongside the research by a consortium of public health experts, the Global Burden of Disease 2016 Injury Collaborators, Studdert and his co-authors write:

“Injuries and deaths from firearms are increasingly part of modern consciousness, particularly in some countries. In the United States, gun-related massacres at schools, places of worship, workplaces, night clubs, and recreational venues have seared images of innocent victims in the minds of the populace. In the United States and elsewhere, acts of terrorism committed with firearms and other lethal means have changed the way people live, work, travel, and play.”

But Studdert and his co-authors — firearms and public health experts Frederick P. Rivara at the University of Washington and Garden J. Wintemute at the University of California, Davis — argue that the deaths from these headline-generating mass shootings and terrorist attacks are only a fraction of the public health burden of firearm-related murders and suicides.

“Mass shootings and terrorism perpetrated with guns are the most visible forms of firearm violence,” Studdert told SHP. “But most firearm deaths are private tragedies. They are homicides and suicides that occur behind closed doors, leaving families and communities devastated.”

The global burden of firearm mortality is highly concentrated, according to the research. In 2016, six countries in the Americas — Brazil, the United States, Mexico, Columbia, Venezuela and Guatemala — accounted for slightlymore than 50 percent of all deaths.

An estimated 32 percent of the deaths occurred in just two countries, Brazil and the United States, with Brazil accounting for one-fourth of all firearm homicides and the United States 35 percent of all firearm suicides.

“For individuals living in the United States, where the national policy debate has focused largely on interpersonal violence, the study provides a reminder of the importance of firearm suicide. In 2016, there were 2 firearm suicides for every firearm homicide, a margin that has widened over the past decade as suicide rates have increased and homicide rates have been relatively flat. Older white non-Hispanic men are at greatest risk of firearm suicide. Research and prevention efforts in the United States should proceed from a more inclusive definition of firearm violence.”

The authors believe more robust methods for estimating the number and distribution of firearms — as well as a better understanding of access — are critically important in determining which policies and prevention strategies are most effective and how best to implement them.

Studdert and his fellow researchers said research on firearm violence and public health has been impeded by the Dickey Amendment, the 1996 bill that mandated “none of the funds made available for injury prevention and control  at the Centers for Disease Control and Prevention may be used to advocate or promote gun control.”

“In the absence of this funding, several private foundations have stepped in to fill the void," they wrote. "However, real progress in addressing the vast public health problem that the Global Burden of Injury Collaborators document will depend on sustained action from governments in both research and policy.”

Federal health advisors say women can now consider three options when it's time for their cervical cancer screening tests. The influential group, the U.S. Preventive Services Task Force (USPSTF), has expanded its recommendations for this potentially life-saving exam.

The new recommendations were published in the latest issue of JAMA.

Pap smears have saved many lives since they became available decades ago. Inspecting samples of cervical tissue for pre-cancerous changes is effective at catching possible cancer, and is still the go-to test for women aged 21 to 29, according to the USPSTF guidelines. But there's another option. 

"Most cervical cancer is caused by what's called the human papilloma virus, or HPV," says Stanford Health Policy's Dr. Douglas Owens, a professor of medicine at Stanford Medicine and vice-chair of the USPSTF. "And we now have tests for HPV and that's an important step forward."

Read the full NPR story